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Deficiency Records for Pavilion Health Center at Brightmore

View the most recent health deficiencies and inspection results for Pavilion Health Center at Brightmore. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Pavilion Health Center at Brightmore. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Ensure medication error rates are not 5 percent or greater. Health 2025-07-03 2025-07-11 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2025-07-03 2025-07-11 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2025-07-03 2025-07-11 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2025-07-03 2025-07-11 N
Ensure each resident receives an accurate assessment. Health 2025-07-03 2025-07-11 N
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Health 2025-07-03 2025-07-11 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-03-26 2024-07-19 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2024-03-26 2024-07-19 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-03-26 2024-07-19 N
Have an externally vented heating system. Fire Safety 2024-03-26 2024-07-19 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-03-26 2024-07-19 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2024-03-26 2024-04-18 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-03-26 2024-04-18 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-03-26 2024-04-18 Y
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2024-03-26 2024-04-18 Y
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Health 2024-03-26 2024-04-18 Y
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2024-03-26 2024-04-18 N
Provide and implement an infection prevention and control program. Health 2024-03-26 2024-04-18 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-03-26 2024-04-18 Y
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2024-03-26 2024-04-18 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-03-26 2024-04-18 N
Provide activities to meet all resident's needs. Health 2024-03-26 2024-04-18 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2024-03-26 2024-04-18 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-03-26 2024-04-18 N
Ensure each resident receives an accurate assessment. Health 2024-03-26 2024-04-18 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2024-03-26 2024-04-18 N
Provide enough food/fluids to maintain a resident's health. Health 2024-03-26 2024-04-18 Y
Ensure that residents are free from significant medication errors. Health 2024-03-26 2024-04-18 Y
Post nurse staffing information every day. Health 2024-03-26 2024-04-16 N
Protect each resident from the wrongful use of the resident's belongings or money. Health 2024-03-26 2024-01-06 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-09-29 2022-12-09 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-09-29 2022-10-17 N
Ensure each resident receives an accurate assessment. Health 2022-09-29 2022-10-17 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-09-29 2022-10-17 N
Provide enough food/fluids to maintain a resident's health. Health 2022-09-29 2022-10-17 N
Provide and implement an infection prevention and control program. Health 2022-09-29 2022-10-17 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-12-09 Not Fixed Y

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